|Year : 2021 | Volume
| Issue : 1 | Page : 91-92
A case of old total Descemet membrane detachment due to ophthalmic viscosurgical device with clear cornea: Microscope-integrated intraoperative optical coherence tomography-guided drainage
Nidhi Kalra1, Mohamed Ibrahime Asif1, Jatinder S Bhalla2, Rahul K Bafna1, Rajesh Sinha1
1 Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 Deen Dayal Upadhyay Hospital, New Delhi, India
|Date of Submission||30-May-2020|
|Date of Acceptance||03-Jun-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Rajesh Sinha
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
We report a case of a large bullous descemet membrane detachment (DMD) following inadvertent injection of ophthalmic viscoelastic device in the supradescemetic space. A 27 years old male with juvenile open-angle glaucoma underwent trabeculectomy in the right eye followed by anterior chamber reformation. He developed DMD for which intracameral gas injection failed twice. He presented with complaints of blurring of images in that eye. Examination revealed a bullous DMD without any corneal edema, confirmed by anterior segment optical coherence tomography (ASOCT). Microscope-integrated intraoperative OCT (mi-OCT) guided drainage with intracameral gas injection was done following which the detachment settled completely.
Keywords: Descemetotomy, descemet membrane detachment, i-OCT, supradescemetic OVD, venting incision
|How to cite this article:|
Kalra N, Asif MI, Bhalla JS, Bafna RK, Sinha R. A case of old total Descemet membrane detachment due to ophthalmic viscosurgical device with clear cornea: Microscope-integrated intraoperative optical coherence tomography-guided drainage. Indian J Ophthalmol Case Rep 2021;1:91-2
|How to cite this URL:|
Kalra N, Asif MI, Bhalla JS, Bafna RK, Sinha R. A case of old total Descemet membrane detachment due to ophthalmic viscosurgical device with clear cornea: Microscope-integrated intraoperative optical coherence tomography-guided drainage. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Mar 2];1:91-2. Available from: https://www.ijoreports.in/text.asp?2021/1/1/91/305503
Descemet membrane detachment (DMD) has been reported to occur following various intraocular surgeries., There are reports of DMD following inadvertent viscoelastic injection in supradescemetic space for post trabeculectomy hypotony.,, Usually in a large DMD there is endothelial pump failure causing diffuse corneal edema. However, we herein report a case of an old bullous DMD with dispersive ophthalmic viscosurgical device (OVD) in supradescemetic space following anterior chamber reformation after trabeculectomy but without any corneal edema. The DMD settled by draining through multiple venting incisions guided by microscope-integrated intraoperative ocular coherence tomography (mi-OCT) and intracameral gas injection.
| Case Report|| |
A 27-year-old male with juvenile open-angle glaucoma presented with blurring and shadowing of images in the right eye for 3 months. He had undergone trabeculectomy in same eye 3 months back. On day 1, following surgery anterior chamber reformation was done with 2% hydroxypropyl methylcellulose (HPMC). In the postoperative period, he was diagnosed to have total DMD. Intracameral C3F8 injection was attempted twice. The patient was put on topical steroids for 6 weeks and later referred to us for management.
On examination, Snellen visual acuity was 6/18 OD and no perception of light OS with intraocular pressure (IOP) of 16 mmHg OD and 24 mm Hg OS. The cornea was clear with a large bullous DMD [Figure 1]a and [Figure 1]b. There was a diffuse superior conjunctival bleb with a patent peripheral iridectomy at 10'Oclock position. Fundus examination revealed a cup disc ratio of 0.7:1 OD and total glaucomatous optic atrophy OS. Anterior Segment OCT (ASOCT) (Visante, Carl Zeiss Meditec AG) of right eye showed corneal thickness of 505μ with a large convex bullous DMD with a height of 1.31 mm [Figure 1]c. In Vivo Confocal microscopy (Rostock Cornea Module, Heidelberg Retina Tomograph 3-HRT3) revealed acellular area suggestive of absence of DM-endothelium complex. Specular microscopy (SP 3000P, Topcon Medical Systems, Inc.) could not capture endothelial layer.
|Figure 1: (a) Slit image of the bullous detachment with the clear cornea. (b) Diffuse image of the DMD with the clear cornea. (c) Preoperative ASOCT revealing a large bullous detachment (1310 microns). (d) ASOCT at 1-week follow-up with a significant decrease in the DMD height (41 microns). (e) Slit image with the complete attachment of DM at a 3-week follow-up. (f) ASOCT with the complete attachment of DM at three-week follow-up|
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The patient was diagnosed as old total bullous DMD OD. Intracameral C3F8 injection, venting incisions, and drainage were planned under MiOCT using RESCAN 700 [microscope integrated iOCT system on Lumera700 (Carl Zeiss Meditec) platform].
A venting incision followed subsequently by three more was made with a microvitreoretinal blade sparing central cornea. A thick viscous substance was drained through the incisions. This led to a decrease in height of the detachment. However, a small detachment still persisted. The stab incisions were then extended through the detached DM under air with mi- OCT visualization to provide a conduit for drainage of the minimally retained OVD into the anterior chamber. This decreased the height of detachment centrally. However, a peripheral pocket of nearly 100μ persisted. Perfluoropropane 14% was injected into anterior chamber with a 30 G needle.
Post-operatively, the patient was prescribed topical prednisolone acetate1% QID, moxifloxacin hydrochloride 0.5% TID, homatropine hydrobromide2% BD and timolol maleate0.5% BD. At 1 week the patient maintained clear cornea with a decrease in the DMD height to 41μ [Figure 1]d. At three-week follow-up, there was complete attachment of DM clinically and on ASOCT [Figure 1]e and [Figure 1]f. The unaided Snellen visual acuity was 6/12 OD, improving to 6/9 (–0.5DCX90°). At 3 months, the patient maintained clear cornea with 6/9 visual acuity.
| Discussion|| |
DMD has rarely been reported following anterior chamber reformation following trabeculectomy. It presents in the early postoperative period with a nonresolving corneal edema., However our patient presented late (three months) because he did not have corneal edema and also because he was initially being managed by the glaucoma surgeon with repeated attempts of intracameral gas injection. Paracentesis in a soft eye with shallow chamber following trabeculectomy might have stripped the Descemet's membrane. Multiple attempts of intracameral C3F8 had failed because of the viscous nature of the supradescemetic content and the tear being insufficient in size to drain the same. Topical steroids were prescribed for 6 weeks probably with the consideration of inflammatory membrane as the cornea was clear despite a large retrocorneal membrane.
Li et al. reported a case of DMD following trabeculectomy which was attached after injecting air, gas, and OVD. A case of clear cornea in spite of a large DMD was reported by Wigginton et al. and managed without surgery.
In our patient, there was no corneal edema, despite a large bullous detachment. We hypothesize that OVD especially dispersive material like HPMC coats the stromal surface preventing imbibition of aqueous into the stroma thereby maintaining corneal clarity.
Venting incisions have been reported to successfully drain supradescemetic fluid leading to complete re-attachment of detached membrane., In our case, venting incisions were preferred over the intracameral approach initially, keeping in mind that the patient was one eyed and intraocular maneuvers would predispose him to greater endothelial damage. However, one venting incision could clear only the area around the incision in that quadrant. Hence subsequently three more venting incisions were made to drain the OVD. mi-OCT helped in providing a continuous visualization of changing height of the supradescemetic space and making two descemetotomies to provide a continuous channel and enable dilution and drainage of OVD in the supradescemetic space. We used a long acting gas in order to have an extended tamponade.
| Conclusion|| |
To conclude, a large bullous DMD with dispersive viscoelastic in supradescemetic space might present with a clear cornea. To perform a successful descemetopexy, adequate drainage of OVD should be done along with intracameral gas injection. mi-OCT is a valuable tool to ensure complete drainage of the viscous fluid.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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